[Date]

[Address]


FOR VALUE RECEIVED, the undersigned hereby assigns 
and transfers to [name], all rights to proceeds, income, rentals, 
fees, profits or monies that shall be due the undersigned from 
[name], under a certain contract described as: 

[Description]

Signed under seal this [date] day of [month, year]. 


________________________________________
(clearly print name after signature)

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